In the post-USPSTF era, patients with prostate cancer presented with more advanced disease

Our study cohort was composed of 282,266 patients at least 40-years-old diagnosed with prostate cancer between January 2010 to December 2012 (pre-USPSTF) and January 2014 to December 2016 (post-USPSTF). There were 152,416 (54.00%) patients in the pre-USPSTF era and 129,850 (46.00%) patients in the post-USPSTF era. The median age of patients in the pre-USPSTF era was 65-years-old (IQR: 59–72-years-old), while that of patients in the post-USPSTF era was 66 (IQR: 60–72-years-old). Median follow-up time was 36 months (IQR: 36–36 months) in the pre-USPSTF era and 16 months (IQR: 8–26 months) in the post-USPSTF era (Table 1).

Table 1 Patient characteristics among insured and uninsured patients

There was a modest but statistically significant change in insurance status from the pre- to post-USPSTF recommendation eras (p < 0.001, chi-squared). Specifically, insured patients decreased from 92.64 to 91.45%, while uninsured patients decreased from 1.90% to 1.33%. Contrastingly, the percentage of Medicaid patients increased from 5.47% to 7.22%. Additionally, patients in the post-USPSTF era presented with higher PSA, biopsy Gleason score (bGS), and higher summary stage, features consistent with more advanced disease (PSA: p < 0.001, bGS: p < 0.001, stage: p < 0.001, chi-squared). These post-USPSTF patients were also less likely to be treated with prostatectomy or radiotherapy (p < 0.001, chi-squared). Among these patients who did not receive local therapy, the proportion of those with regional and distant cancer increased across the eras from 3.11 to 4.08% and 8.89 to 12.71%, respectively, while those with localized disease decreased from 88.00 to 83.20% (Table 2; p < 0.001, chi-squared).

Table 2 Stage distribution of patients who did not receive local therapy from the pre-USPSTF (2010–2012) to post-USPSTF eras (2014–2016)

Factors associated with decreased PCSS included coverage with Medicaid, uninsured, and non-Hispanic Black, higher PSA, bGS, and stage, and not receiving local treatment. In contrast, being non-Hispanic Asian/Pacific Islander was associated with increased PCSS. When analyzing the two eras separately using an adjusted Cox proportional hazards model, however, there were no survival disparities between non-Hispanic White and Black patients (Tables 3 and 4).

Table 3 Cox proportional hazards analysis of factors associated with prostate cancer-cause specific survival in the pre-USPSTF era (2010–2012)
Table 4 Cox proportional hazards analysis of factors associated with prostate cancer-cause specific survival in the post-USPSTF era (2014–2016)

Adjusted PCSS disparities between insured and uninsured groups disappeared in the post-USPSTF era

Across both eras, there were 226,997 insured, 15,435 Medicaid, and 4,041 uninsured patients. Of the insured patients, 54.88% (n = 124,577) and 45.12% (n = 102,420) were in the pre- and post-USPSTF eras, respectively. Of the Medicaid patients, 47.63% (n = 7,351) and 52.37% (n = 8,084) were in the pre- and post-eras, respectively. Of the uninsured patients, 63.15% (n = 2,552) and 36.85% (n = 1,489) were in the pre- and post-USPSTF eras, respectively.

From the pre- to post-USPSTF era, the changes in PSA between insured and uninsured patients as well as insured and Medicaid patients were statistically significant with insured patients experiencing a greater increase in those with a PSA greater than 10 ng/ml but less than or equal to 20 ng/ml than uninsured and Medicaid patients (p = 0.048 and p < 0.001, respectively, multinomial logistic regression with generalized logit function [LR]). Compared to insured patients, however, uninsured patients experienced a greater increase in those with a PSA greater than 20 ng/ml. Insured patients also presented with higher bGS than uninsured and Medicaid patients with the proportion of those with bGS less than or equal to 6 decreasing from 45.40% (n = 51,845) to 34.23% (n = 32,133), bGS of 7 increasing from 38.00% (n = 43,401) to 42.45% (n = 39,845), and bGS greater than or equal to 8 increasing from 16.60% (n = 18,959) to 23.32% (n = 21,884) (p = 0.004 and p < 0.001, respectively, LR). Lastly, while insured and uninsured patients experienced similar shifts in local treatment from the pre- to post-USPSTF era (p = 0.524, LR), insured patients experienced a greater decrease in prostatectomy and radiotherapy relative to Medicaid patients (p < 0.001, LR).

During the pre-USPSTF era, uninsured patients experienced worse PCSS than insured patients (Fig. 1a; HR 2.512, 95% CI 2.813–2.889, p < 0.001). This survival disparity narrowed as a result of a statistically significant decrease in PCSS among insured patients (Figs. 1b and 1c; p < 0.001, log-rank) and no statistically significant change in PCSS among uninsured patients (Fig. 1e; p = 0.271, log-rank) (HR 1.980, 95% CI 1.564–2.505, p < 0.001). When adjusted for factors such as age, race, and PSA, however, the PCSS disparity between insured and uninsured patients in the pre-USPSTF era disappeared altogether in the post era (Tables 3 and 4; pre-USPSTF: aHR 1.256, 95% CI 1.037–1.520, p = 0.020; post-USPSTF: aHR 0.946, 95% CI 0.642–1.394, p = 0.780). In addition, in both the pre- and post-USPSTF era, there was no survival disparity between White and Blacks when insurance status was adjusted in addition to clinical features (Table 3, aHR 1.072, 95% CI 0.971–1.183, p = 0.167). In contrast, the survival disparity between Medicaid and insured patients from the pre- to post-USPSTF era did not significantly change with Medicaid patients continuing to experience decreased survival relative to insured patients (Fig. 1d; pre: aHR 1.309, 95% CI 1.157–1.481, p < 0.001; post: aHR 1.230, 95% CI 1.040–1.454, p = 0.015; p = 0.553, two-tailed test).

Fig. 1
figure 1

A 3-year prostate cancer-specific survival of insured and uninsured patients with prostate cancer in 2010–2012 (pre-USPSTF era). B 3-year prostate cancer-specific survival of insured and uninsured patients with prostate cancer in 2014–2016 (post-USPSTF era) C 3-year prostate cancer-specific survival of insured patients with prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). D 3-year prostate cancer-specific survival of Medicaid patients with prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). E 3-year prostate cancer-specific survival of uninsured patients with prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). Prostate cancer-specific survival of insured and Medicaid patients with prostate cancer worsened from 2010–2012 to 2014–2016, while that of uninsured patients did not change

While insured patients experienced worse survival, and uninsured patients did not observe a survival change across all stages of prostate cancer, adjusted PCSS disparities between insured and uninsured groups disappeared in the post-USPSTF era for distant prostate cancer

Insured patients across all stages of prostate cancer experienced a statistically significant decrease in survival from the pre- to post-USPSTF eras, while Medicaid and uninsured patients did not experience a survival change (Fig. 2). In an adjusted Cox proportional hazards model stratified by stage, however, there were no statistically significant survival disparities between insured and uninsured patients with localized or regional prostate cancer in both the pre- and post-USPSTF eras (Table 5; pre-USPSTF, uninsured and localized: aHR 1.089, 95% CI 0.657–1.803, p = 0.742; post-USPSTF, uninsured and localized: aHR 0.805, 95% CI 0.256–2.531, p = 0.711; pre-USPSTF uninsured and regional: aHR 1.556, 95% CI 0.758–3.191, p = 0.228; post-USPSTF uninsured and regional: subgroup too small for hazard ratio calculation). For patients with distant prostate cancer, there was a survival disparity between insured and uninsured patients in the pre-USPSTF era that disappeared in the post-USPSTF era (pre-USPSTF, uninsured and distant: aHR 1.244, 95% CI 1.002–1.545, p = 0.048; post-USPSTF, uninsured and distant: aHR 1.048, 95% CI 0.693–1.586, p = 0.824).

Fig. 2
figure 2

A 3-year prostate cancer-specific survival of insured patients with localized prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). B 3-year prostate cancer-specific survival of Medicaid patients with localized prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). C 3-year prostate cancer-specific survival of uninsured patients with localized prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). D 3-year prostate cancer-specific survival of insured patients with regional prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). E 3-year prostate cancer-specific survival of Medicaid patients with regional prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). F 3-year prostate cancer-specific survival of uninsured patients with regional prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). G 3-year prostate cancer-specific survival of insured patients with metastatic prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). H 3-year prostate cancer-specific survival of Medicaid patients with metastatic prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). I 3-year prostate cancer-specific survival of uninsured patients with metastatic prostate cancer in 2010–2012 (pre-USPSTF era) and 2014–2016 (post-USPSTF era). Prostate cancer-specific survival of insured patients across all stages of prostate cancer worsened from 2010–2012 to 2014–2016, while Medicaid and uninsured patients across all stages did not change

Table 5 Cox proportional hazards analysis of insurance status associated with prostate cancer-cause specific survival by era and stage

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